This summary of the autism mandated benefit bill winning final approval last week comes from the Legislature. It is a chapter in formal session summaries to be released in the next couple of work days.

CS/CS/CS/SB 2654 — Children with Disabilities - by Health and Human Services Appropriations Committee, Health Policy Committee, Banking and Insurance Committee, and Senator Geller and others

Senate Bill 2654 authorizes the Agency for Health Care Administration (AHCA or Agency) to seek federal approval through a Medicaid waiver or state plan amendment for the provision of occupational therapy, speech therapy, physical therapy, behavior analysis, and behavior assistant services to individuals who are 5 years old and younger and have a diagnosed developmental disability, an autism spectrum disorder, or Down syndrome. Coverage for such services must be limited to $36,000 annually and $108,000 in total lifetime benefits. The agency must submit an annual report beginning on January 1, 2009 to the Legislature regarding progress on obtaining federal approval and recommendations for the implementation of services. The agency may not implement the provision of these services without prior legislative approval.

The bill creates the “Window of Opportunity Act” which requires the Office of Insurance Regulation (OIR or Office) to convene a workgroup by August 31, 2008, to negotiate a binding compact agreement among participants relating to insurance and access to services for persons with developmental disabilities. The working group must include representatives from all licensed health insurers, all licensed health maintenance organizations, and employers with self insured health benefit plans. No party must agree to the compact, but a party that does agree to the compact is bound to its terms and conditions. The compact agreement must include: 
•    A requirement to increase coverage for behavior analysis and behavior assistant services, speech therapy, physical therapy, and occupational therapy due to the presence of a developmental disability.
•    Procedures for clear and specific notice to policyholders identifying the amount, scope, and conditions under which coverage is provided for such services. 
•    Penalties for documented cases of denial of claims for medically necessary services due to the presence of a developmental disability.
•    Proposals for new product lines to be offered in conjunction with health insurance.

Once the compact agreement negations are completed, the OIR must report the results to the Governor, President of the Senate, and Speaker of the House of Representatives. Beginning February 15, 2009, the OIR must submit an annual report regarding the implementation of the compact agreement.

The bill also creates the “Steven A. Geller Autism Coverage Act” which requires insurer large group health insurance plans and HMO large group health maintenance contracts to provide coverage for diagnostic screening, intervention, and treatment of autism spectrum disorder in children through speech therapy, occupational therapy, physical therapy, and applied behavior analysis that is prescribed by the insured’s treating physician in accordance with a treatment plan. All large group health insurance policies and HMO contracts issued or renewed on or after April 1, 2009, must provide the mandated autism spectrum coverage, except that the mandate is not enforceable against an insurer or HMO that is a signatory of the developmental disabilities compact for developmental disabilities, described above, as of April 1, 2009. However, the autism spectrum mandate is enforceable against a signatory of the developmental disabilities compact if the insurer or HMO has not complied with the terms of the compact by April 1, 2010.

The mandatory coverage for autism spectrum disorder is subject to a maximum benefit of $36,000 per year not to exceed $200,000 in total lifetime benefits. Beginning January 1, 2011, the maximum benefit is to be adjusted annually on that date to reflect annual changes in the medical inflation component of the Consumer Price Index. To be eligible for benefits and coverage, an individual must be diagnosed with an autism spectrum disorder at 8 years of age or younger. Benefits and coverage must be provided to eligible persons who are under 18 years of age or who are in high school. Coverage may not be subject to dollar limits, deductibles, or coinsurance provisions that are less favorable than those applied to covered physical illnesses under the health plan or contract, except as allowed by the act. The coverage for autism may be subject to other general exclusions and limitations of the insurer or HMO’s policy or plan. Benefits may not be denied on the basis that provided services are habilitative in nature.

Health insurance plans and HMOs may not deny, refuse to issue or reissue coverage, terminate, or restrict coverage because an individual is diagnosed with autism spectrum disorder.

If approved by the Governor, these provisions take effect July 1, 2008
Vote:  Senate 40 0; House 118 0